Nephrology Practice Questions

Q: A child presented with cola-colored urine, proteinuria (2+), and history of rash 2 weeks ago. The most probable diagnosis is

HSP. ***HSP*** - **Henoch-Schönlein Purpura (HSP)** often presents with a characteristic **rash**, abdominal pain, and arthritis, followed by renal involvement manifested as **cola-colored urine** and **proteinuria**. - The rash (palpable purpura) appearing two weeks prior to the renal symptoms is a classic timeline for **HSP nephritis**. *HUS* - **Hemolytic Uremic Syndrome (HUS)** is characterized by a triad of **hemolytic anemia**, **thrombocytopenia**, and **acute kidney injury**, often preceded by a diarrheal illness (e.g., E. coli O157:H7 infection). - While it causes acute kidney injury, the primary presentation in the question (rash followed by cola-colored urine) is not typical for HUS. *IgA nephropathy* - **IgA nephropathy** often presents with **recurrent macroscopic hematuria** (cola-colored urine) usually occurring concurrently with or shortly after an upper respiratory or gastrointestinal infection. - However, the history of a preceding generalized rash two weeks ago is not a classic feature of IgA nephropathy. *Wegener Granulomatosis* - **Wegener Granulomatosis** (now known as **Granulomatosis with Polyangiitis**) is a systemic vasculitis affecting small to medium-sized vessels, typically involving the **upper and lower respiratory tracts** and **kidneys**. - Its presentation usually includes symptoms like chronic sinusitis, pulmonary infiltrates, and rapidly progressive glomerulonephritis, without the characteristic preceding rash described.

Q: A three-year-old boy presents with a poor urinary stream. Most likely cause is -

Posterior urethral valve. ***Posterior urethral valve*** - **Posterior urethral valve (PUV)** is the most common cause of **urethral obstruction** in male neonates and infants, leading to a poor urinary stream. - The obstruction is caused by abnormal folds of tissue in the **posterior urethra**, which impede urine flow from the bladder. *Stricture urethra* - While urethral strictures can cause a poor urinary stream, they are more commonly acquired through **trauma, infection, or instrumentation** and are less common in a 3-year-old boy as an initial presentation. - **Congenital urethral strictures** are rare and typically found more distally than PUV. *Neurogenic bladder* - **Neurogenic bladder** results from impaired neurological control over bladder function, leading to issues like poor stream, incontinence, or retention. - Although it can cause a poor stream, it is usually associated with other neurological signs or a history of **spinal cord anomalies** (e.g., myelomeningocele), which are not mentioned. *Urethral calculus* - **Urethral calculi** (stones) can obstruct urine flow and cause a poor stream, but they are relatively rare in a 3-year-old child without predisposing factors like metabolic abnormalities or recurrent urinary tract infections. - The presentation would typically include sudden onset of pain, hematuria, and potentially a history of prior stones.

Q: A 3-year-old boy presents with fever, dysuria and gross hematuria. Physical examination shows a prominent suprapubic area which is dull on percussion. Urinalysis reveals red blood cells but no proteinuria. Which of the following is the most likely diagnosis -

Posterior urethral valves. ***Posterior urethral valves*** - The combination of **fever**, **dysuria**, **gross hematuria**, and a **prominent, dull suprapubic area** (suggesting a distended bladder) in a young male child points to an obstructive uropathy. - **Posterior urethral valves** are the most common cause of lower urinary tract obstruction in male infants and young children, leading to bladder outlet obstruction, urinary retention, and potential hydronephrosis. *Acute glomerulonephritis* - While it can cause hematuria, it typically presents with **proteinuria**, **edema**, and **hypertension**, which are not present in this case. - The prominent, dull suprapubic area is not a characteristic finding for acute glomerulonephritis. *Urinary tract infection* - A **UTI** can cause fever and dysuria, but significant **gross hematuria** and a **prominent suprapubic area** (indicating bladder distention) are less typical initial presentations. - While possible, the strong evidence of obstruction makes another diagnosis more likely. *Teratoma* - A **teratoma** is a tumor, which might present with a mass, but the constellation of acute symptoms including fever, dysuria, and a distended bladder points away from a primary diagnosis of teratoma. - Teratomas in the urinary tract are rare and usually present with non-specific symptoms or a palpable mass rather than acute obstructive signs.

Q: A 10-year-old child with a history of frequent micturition and fever since 2 years presents to the pediatric OPD. On examination, it was normal. What would be the MOST APPROPRIATE diagnostic modality for this child?

3D MCU. ***3D MCU (Micturating Cystourethrogram)*** - **Gold standard** for diagnosing **vesicoureteral reflux (VUR)**, the most common cause of recurrent UTIs in children - In a child with **2-year history of recurrent UTIs** (fever + frequent micturition), VUR is the primary concern that needs to be ruled out - MCU provides **dynamic imaging** during bladder filling and voiding, allowing direct visualization of **reflux** and assessment of **bladder and urethral anatomy** - **Standard of care** recommended by IAP (Indian Academy of Pediatrics) and major pediatric nephrology guidelines - Though it involves ionizing radiation, the **diagnostic benefit far outweighs risks** in this clinical scenario - Cost-effective and widely available in Indian healthcare settings *MR Urogram* - Provides excellent anatomical detail of the **upper urinary tract** (kidneys, ureters) without radiation - However, it is **NOT the first-line investigation** for recurrent UTI workup in children - Does not adequately assess **dynamic VUR** like MCU does - More expensive, requires sedation in many children, and less accessible - Reserved for specific indications like suspected anatomical anomalies after initial screening *3D CT Urogram* - Excellent for detailed anatomical evaluation but involves **high radiation dose** - Not appropriate as first-line investigation in a **chronic, non-acute pediatric case** - Reserved for complex cases where MR is contraindicated or for acute complications *IVP (Intravenous Pyelogram)* - **Obsolete modality** that has been replaced by ultrasound, MCU, and modern cross-sectional imaging - Provides limited functional and anatomical information - Higher radiation exposure with inferior image quality compared to modern techniques - Not used in current pediatric practice

Q: A 2-year-old child presents with sudden onset of altered sensorium. On examination, blood pressure is 200/100 mmHg. What is the most likely diagnosis?

Glomerulonephritis. ***Glomerulonephritis*** - The sudden onset of **altered sensorium** in a 2-year-old with severe **hypertension** (200/100 mmHg) is highly suggestive of **hypertensive encephalopathy**, a serious complication often seen in acute glomerulonephritis. - **Acute glomerulonephritis**, particularly post-streptococcal glomerulonephritis, frequently presents with sudden onset of hypertension, fluid retention, and neurological symptoms such as altered sensorium in young children. *Renal artery stenosis* - While renal artery stenosis can cause severe hypertension, it typically does not present with such an acute and dramatic onset of altered sensorium in a 2-year-old, unless there's a thrombotic event. - Hypertensive encephalopathy secondary to renal artery stenosis is possible but less common as the initial presentation in this age group compared to acute glomerulonephritis. *Essential hypertension* - **Essential hypertension** is extremely rare in a 2-year-old and would not typically present with such a severe, sudden onset of hypertension leading to altered sensorium. - When hypertension is diagnosed in young children, an underlying **secondary cause** is almost always present and must be aggressively investigated. *Coarctation of Aorta* - **Coarctation of the aorta** causes hypertension, but the hypertension is usually present from birth or early infancy and would typically manifest with a **difference in blood pressure** between the upper and lower extremities and specific murmur. - While it can lead to high blood pressure, an acute presentation with sudden altered sensorium due to extremely high pressure is less characteristic compared to the acute inflammatory process of glomerulonephritis.

Q: Lowest recurrence in nocturnal enuresis is seen with-

Bed alarms. ***Bed alarms*** - **Bed alarms** are the most effective long-term treatment for nocturnal enuresis due to their ability to condition the child to wake up to the sensation of a full bladder, leading to the **lowest recurrence rates**. - This method provides a **behavioral solution** by teaching the brain to recognize and respond to bladder signals, thus addressing the underlying issue rather than just managing symptoms. *Oxybutynin* - **Oxybutynin** is an anticholinergic medication that primarily works by reducing **detrusor muscle overactivity**, which can contribute to enuresis. - While effective for some, its action is primarily symptomatic, and recurrence rates are higher once the medication is stopped compared to behavioral approaches. *Desmopressin* - **Desmopressin** is an analog of **vasopressin** that reduces urine production overnight, addressing a potential deficiency in ADH secretion. - While it can significantly reduce enuretic episodes during treatment, its effect is mostly symptomatic, and the **relapse rate** upon discontinuation is considerable. *Imipramine* - **Imipramine**, a tricyclic antidepressant, works through multiple mechanisms, including anticholinergic effects, central nervous system stimulation, and deep sleep reduction. - It has a higher risk of **side effects** and, similar to desmopressin and oxybutynin, its benefits often cease once the medication is stopped, resulting in higher recurrence.

Q: In SCHWARTZ formula for calculation of creatinine clearance in a child, the constant depends on the following except –

Severity of renal failure. ***Severity of renal failure*** - The constant in the **Schwartz formula** primarily accounts for factors like muscle mass and maturation, not the severity of renal failure itself. - The formula is designed to estimate glomerular filtration rate (GFR) over a range of renal function, with the creatinine value reflecting the severity, not the constant. *Age* - The original Schwartz formula uses an age-dependent constant, with different values for infants, children, and adolescents, reflecting changes in **muscle mass** and **creatinine generation** with age. - Specifically, constants like 0.33, 0.45, 0.55, and 0.65 are used depending on the patient's age group. *Mass* - The constant implicitly accounts for differences in **muscle mass** and body composition, which are related to age and sex, influencing creatinine production. - The formula itself includes **height** in cm as a direct variable, which is a proxy for lean body mass. *Method of estimation of creatinine* - The constant is adjusted based on the method used to measure **serum creatinine**, specifically whether it's an **enzymatic** method or a **Jaffe reaction-based** method. - Different constants are necessary because Jaffe assays can overestimate true creatinine levels due to interference from non-creatinine chromogens.

Q: A 10-year-old boy presents with hypertension. There is no history of urinary tract infections, abdominal pain, or family history of renal disease. Urine analysis reveals microscopic hematuria, proteinuria, and red blood cell casts. What is the most likely diagnosis?

Chronic glomerulonephritis. ***Chronic glomerulonephritis*** - The combination of **microscopic hematuria, proteinuria, and RBC casts** is pathognomonic for **glomerular disease**. - **RBC casts** specifically indicate glomerular bleeding and are highly specific for **glomerulonephritis**. - **Hypertension** in chronic glomerulonephritis results from sodium retention, fluid overload, and activation of the renin-angiotensin-aldosterone system. - The absence of acute features suggests a **chronic** process rather than acute post-streptococcal glomerulonephritis. *Reflux nephropathy* - While reflux nephropathy can cause hypertension and proteinuria, it typically presents with a history of **recurrent urinary tract infections**, which is explicitly absent in this case. - **RBC casts are NOT a feature** of reflux nephropathy; urinalysis may show proteinuria and occasionally WBCs/bacteria if infection is present. - Diagnosis requires imaging (VCUG, DMSA scan) showing vesicoureteral reflux and renal scarring. *Polycystic kidney disease* - **Autosomal dominant PKD** rarely presents with symptoms in childhood; it typically manifests in the 3rd-4th decade. - **Autosomal recessive PKD** presents in infancy/early childhood with enlarged kidneys and renal failure. - While PKD can cause hematuria (from cyst rupture), **RBC casts are not characteristic** as the pathology is cystic, not glomerular. - Diagnosis is made by ultrasound showing multiple bilateral renal cysts. *All of the options* - This is incorrect because the **specific urinalysis findings** (particularly **RBC casts**) point definitively to **glomerular pathology**. - RBC casts are the hallmark of glomerulonephritis and are not seen in reflux nephropathy or polycystic kidney disease. - The clinical presentation with specific laboratory findings allows differentiation between these conditions.

Question 1

A child presented with cola-colored urine, proteinuria (2+), and history of rash 2 weeks ago. The most probable diagnosis is

Accepted Answer

HSP

Answer

HUS

Answer

IgA nephropathy

Answer

Wegener Granulomatosis

Question 2

A three-year-old boy presents with a poor urinary stream. Most likely cause is -

Accepted Answer

Posterior urethral valve

Answer

Stricture urethra

Answer

Neurogenic bladder

Answer

Urethral calculus

Question 3

A 3-year-old boy presents with fever, dysuria and gross hematuria. Physical examination shows a prominent suprapubic area which is dull on percussion. Urinalysis reveals red blood cells but no proteinuria. Which of the following is the most likely diagnosis -

Accepted Answer

Posterior urethral valves

Answer

Acute glomerulonephritis

Answer

Urinary tract infection

Answer

Teratoma

Question 4

A 10-year-old child with a history of frequent micturition and fever since 2 years presents to the pediatric OPD. On examination, it was normal. What would be the MOST APPROPRIATE diagnostic modality for this child?

Accepted Answer

3D MCU

Answer

MR UROGRAM

Answer

3D CT UROGRAM

Answer

IVP

Question 5

A 5-year old child of severe nephrotic syndrome on treatment with tacrolimus, frusemide and prednisolone developed seizures. The investigations revealed:
Serum Na+ = 136 mEq/L
Blood urea = 78 mg/dL
Serum creatinine = 0.5 mg/dL
Serum albumin = 1.5 g/dL
Serum total Ca = 7.5 mg/dL
Urine albumin = 2g
What is the likely cause of symptoms in this child?

Accepted Answer

Hypocalcemia

Answer

Tacrolimus toxicity

Answer

Uremia

Answer

Hyponatremia

Question 6

A 2-year-old child presents with sudden onset of altered sensorium. On examination, blood pressure is 200/100 mmHg. What is the most likely diagnosis?

Accepted Answer

Glomerulonephritis

Answer

Renal artery stenosis

Answer

Essential hypertension

Answer

Coarctation of Aorta

Question 7

What is the best method to estimate the amount of proteinuria in a 2-year-old child with nephrotic syndrome?

Accepted Answer

Single morning spot urine sample for protein/creatinine ratio

Answer

24 hr urine protein

Answer

Dipstick testing

Answer

Microalbuminuria

Question 8

Lowest recurrence in nocturnal enuresis is seen with-

Accepted Answer

Bed alarms

Answer

Oxybutynin

Answer

Desmopressin

Answer

Imipramine

Question 9

In SCHWARTZ formula for calculation of creatinine clearance in a child, the constant depends on the following except –

Accepted Answer

Severity of renal failure

Answer

Age

Answer

Mass

Answer

Method of estimation of creatinine

Question 10

A 10-year-old boy presents with hypertension. There is no history of urinary tract infections, abdominal pain, or family history of renal disease. Urine analysis reveals microscopic hematuria, proteinuria, and red blood cell casts. What is the most likely diagnosis?

Accepted Answer

Chronic glomerulonephritis

Answer

Reflux nephropathy

Answer

Polycystic kidney disease

Answer

All of the options

Nephrology — MCQs

Nephrology — MCQs

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